CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 2, March/April 2010
AFRICA
109
Case Report
Amiodarone-induced QT prolongation in a newly
transplanted heart associated with recurrent ventricular
fibrillation
ERNST R SCHWARZ, LAWRENCE S CZER, SINAN A SIMSIR, ROBERT M KASS, ALFREDO TRENTO
Summary
Anti-arrhythmic drugs such as amiodarone have the potential
to prolong QT intervals, which can result in torsades de point
arrhythmia. It is unknown whether amiodarone, given to a
recipient prior to cardiac transplantation, can cause arrhyth-
mia in a newly transplanted donor heart.We report on a case
of a 71-year-old male patient who had received intravenous
and oral amiodarone prior to transplantation, which was
associated with QT prolongation in the transplanted heart
after re-exposure to the drug during subsequent episodes of
ventricular fibrillation. An ICD was implanted, which has
not been described that soon after cardiac transplantation.
Amiodarone, given to a recipient, might cause QT prolonga-
tion in a donor heart after transplantation, possibly due to its
long half-life and increased bioavailability caused by interac-
tion with immunosuppressive drugs.
Keywords:
ventricular fibrillation, QT prolongation, anti-
arrhythmic drugs, heart transplantation
Submitted 3/7/09, accepted 19/8/09
Cardiovasc J Afr
2010;
21
: 109–112
Cardiac transplantation represents the ultimate therapeutic solu-
tion for end-stage heart failure. Currently, approximately 2 200
heart transplantations are performed in the USA per year.
1
Survival rates at one, five and 10 years after cardiac transplanta-
tion are reported as 87, 77 and 57%, respectively. The average
life expectancy after cardiac transplantation is approximately 10
years in adults (9.16 years in a recent study
2
). Quality of life in
patients 10 years after heart transplantation has been described
as similar to that in the general population.
2
Arrhythmias early
after transplant surgery, in particular paroxysmal atrial fibrilla-
tion, have been described in 5% of cases,
3
even independent of
evidence of cellular or humoral rejection.
In a large retrospective analysis, cardiac transplantation – in
contrast to CABG surgery in low-risk patients – was considered
the strongest independent predictor of freedom from postopera-
tive atrial fibrillation (odds ratio 96; 95% confidence interval:
13–720).
4
The incidence of atrial fibrillation, atrial flutter and
supraventricular tachycardia after cardiac transplantation was
reported as 0.33, 2.8 and 1.3%, respectively.
4
Early postoperative
supraventricular arrhythmias are usually of a transient nature and
rarely require specific anti-arrhythmic therapy.
In contrast, the potential pro-arrhythmogenic effects of anti-
arrhythmic drugs are well known.
5
QT prolongation with subse-
quent torsade de point arrhythmias, in particular after amiodar-
one therapy potentially resulting in ventricular fibrillation, has
been described repeatedly.
6-8
We report on a patient with end-stage heart failure treated
with intravenous amiodarone followed by oral amiodarone prior
to cardiac transplantation. With a single intravenous re-exposure
to the drug after transplantation for an episode of atrial fibril-
lation, the patient developed QT prolongation with subsequent
ventricular fibrillation, requiring ICD implantation soon after
transplant. This has not been reported before.
Case report
The patient was a 71-year-old male with a long-standing history
of cardiovascular disease, coronary artery disease, status post
myocardial infarction 14 years ago, who underwent coronary
artery bypass grafting seven years earlier with a mammary graft
to the left anterior descending artery, a vein graft to the diagonal
branch, a vein graft to the marginal branch, and a vein graft to
the right coronary artery. Over the past five years, the patient
had developed symptomatic heart failure, most likely due to
myocardial ischaemia.
Echocardiography demonstrated severe left ventricular
dysfunction with an ejection fraction of 16% and severe mitral
regurgitation. Coronary angiography showed occlusion of all
grafts except the mammary artery graft. Due to severe coronary
sclerosis in the native coronary arteries, no interventional or
surgical options for revascularisation were considered. After
repeated outside hospital admissions for acute decompensated
heart failure, the patient was referred in congestive heart failure
NewYork Heart Association class IV, stage D, for advanced heart
failure therapy.
The patient had a left bundle branch block and a cardio-
verter/defibrillator/biventricular pacemaker (CRTD) device was
implanted for cardiac resynchronisation therapy and sudden
death prophylaxis. Due to persistent symptoms of heart failure
Cedars Sinai Heart Institute, Division of Cardiology, Division
of Cardiothoracic Surgery, Comprehensive Transplant Center,
Cedars Sinai Medical Center, Los Angeles, and University of
California Los Angeles, (UCLA), Los Angeles, USA
ERNST R SCHWARZ, MD, PhD,
LAWRENCE S CZER, MD
SINAN A SIMSIR, MD
ROBERT M KASS, MD
ALFREDO TRENTO, MD
